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Clinical Psychology Review 34 (2014) 158176

Contents lists available at ScienceDirect

Clinical Psychology Review

Participation and outcome in manualized self-help for bulimia nervosa


and binge eating disorder A systematic review and
metaregression analysis
Ina Beintner a,, Corinna Jacobi a, Ulrike H. Schmidt b
a
b

Institut fr Klinische Psychologie und Psychotherapie, Technische Universitt Dresden, Chemnitzer Strae 46, 01187 Dresden, Germany
King's College London, Institute of Psychiatry, Box P059, De Crespigny Park, London SE5 8AF, UK

H I G H L I G H T S

Adherence is an issue in self-help interventions for mental disorders.


Dropout and treatment completion rates and denitions of treatment completion vary.
BED patients complete self-help more often and benet more than BN patients.
For BN patients, guidance can reduce study dropout and enhance treatment outcome.
For further research on adherence, comparable measures are needed.

a r t i c l e

i n f o

Article history:
Received 7 August 2013
Received in revised form 7 January 2014
Accepted 14 January 2014
Available online 23 January 2014
Keywords:
Self-help
Adherence
Binge eating
Bulimia nervosa
Metaregression

a b s t r a c t
There is a growing body of research on manualized self-help interventions for bulimia nervosa (BN) and binge
eating disorder (BED). Study and treatment dropout and adherence represent particular challenges in these studies. However, systematic investigations of the relationship between study, intervention and patient characteristics, participation, and intervention outcomes are lacking. We conducted a systematic literature review using
electronic databases and hand searches of relevant journals. In metaregression analyses, we analyzed study dropout as well as more specic measures of treatment participation in manualized self-help interventions, their
association with intervention characteristics (e.g. duration, guidance, intervention type [bibliotherapy, CDROM or Internet based intervention]) and their association with treatment outcomes. Seventy-three publications
reporting on 50 different trials of manualized self-help interventions for binge eating and bulimia nervosa published through July 9th 2012 were identied. Across studies, dropout rates ranged from 1% to 88%. Study dropout
rates were highest in CD-ROM interventions and lowest in Internet-based interventions. They were higher
in samples of BN patients, samples of patients with higher degrees of dietary restraint at baseline, lower age,
and lower body mass index. Between 6% and 88% of patients completed the intervention to which they had
been assigned. None of the patient, study and intervention characteristics predicted intervention completion rates. Intervention outcomes were moderated by the provision of personal guidance by a health professional, the number of guidance sessions as well as participants' age, BMI, and eating disorder related
attitudes (Restraint, Eating, Weight and Shape Concerns) at baseline (after adjusting for study dropout
and intervention completion rates). Guidance particularly improved adherence and outcomes in samples
of patients with bulimia nervosa; specialist guidance led to higher intervention completion rates and larger
intervention effects on some outcomes than non-specialist guidance. Self-help interventions have a place in
the treatment of BN and BED, especially if the features of their delivery and indications are considered carefully.
To better determine who benets most from what kind and dosage of self-help interventions, we recommend
the use of consistent terminology as well as uniform standards for reporting adherence and participation in
future self-help trials.
2014 Elsevier Ltd. All rights reserved.

Some of the results were presented at the 18th annual meeting of the Eating Disorder Research Society (EDRS), September 21th 2012, Porto (Portugal).
Corresponding author. Tel.: +49 351 463 37460; fax: +49 351 463 37208.
E-mail addresses: Ina.Beintner@tu-dresden.de (I. Beintner), corinna.jacobi@tu-dresden.de (C. Jacobi), ulrike.schmidt@kcl.ac.uk (U.H. Schmidt).
0272-7358/$ see front matter 2014 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.cpr.2014.01.003

I. Beintner et al. / Clinical Psychology Review 34 (2014) 158176

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Contents
1.
2.

Introduction . . . . . . . . . . . . . . . . . . . . . . . .
Methods . . . . . . . . . . . . . . . . . . . . . . . . . .
2.1.
Study selection
. . . . . . . . . . . . . . . . . . .
2.2.
Measures of participation . . . . . . . . . . . . . . .
2.3.
Effect size calculation for intervention outcomes
. . . .
2.4.
Coding
. . . . . . . . . . . . . . . . . . . . . . .
2.4.1.
Study participation and study outcomes . . . .
2.4.2.
Study and intervention characteristics . . . . .
2.4.3.
Patient characteristics
. . . . . . . . . . . .
2.5.
Integration of outcomes
. . . . . . . . . . . . . . .
2.6.
Moderator analyses
. . . . . . . . . . . . . . . . .
2.7.
Sensitivity analyses . . . . . . . . . . . . . . . . . .
3.
Results
. . . . . . . . . . . . . . . . . . . . . . . . . .
3.1.
Sample of studies
. . . . . . . . . . . . . . . . . .
3.2.
Participation . . . . . . . . . . . . . . . . . . . . .
3.3.
Moderators of participation . . . . . . . . . . . . . .
3.3.1.
Study dropout rate
. . . . . . . . . . . . .
3.3.2.
Intervention completion rate . . . . . . . . .
3.3.3.
High participation . . . . . . . . . . . . . .
3.3.4.
Low participation
. . . . . . . . . . . . . .
3.4.
Intervention outcomes . . . . . . . . . . . . . . . .
3.5.
Moderators of intervention outcomes across trials . . . .
3.5.1.
Study and intervention characteristics . . . . .
3.5.2.
Patient characteristics
. . . . . . . . . . . .
3.6.
Sensitivity analyses . . . . . . . . . . . . . . . . . .
4.
Discussion . . . . . . . . . . . . . . . . . . . . . . . . .
4.1.
Measures of participation . . . . . . . . . . . . . . .
4.2.
Moderators of participation . . . . . . . . . . . . . .
4.3.
Moderators of intervention outcomes
. . . . . . . . .
4.4.
Implications for the design of future interventions . . . .
4.4.1.
How should self-help interventions be designed
4.4.2.
Who benets most from self-help interventions?
4.5.
Clinical recommendations
. . . . . . . . . . . . . .
4.6.
Limitations of our metaanalysis
. . . . . . . . . . . .
5.
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . .
Appendix A. Supplementary data
. . . . . . . . . . . . . . . . .
References
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1. Introduction
Around the world, national strategy documents and inuential
reviews highlight the need for urgent action to improve the state of
mental health care (e.g., Kazdin & Blase, 2011; Medical Research
Council, 2010; Patel, Boyce, Collins, Saxena, & Horton, 2011). Access to
evidence-based psychological interventions poses a key determinant
of good outcomes (The Centre for Economic Performance's Mental
Health Policy Group, 2012). However, given the cost of face-to-face individual psychological therapy (which is the currently predominant
model of intervention delivery) to health care systems and patients,
cost-effective alternatives are needed (Kazdin & Blase, 2011). In this
context, translating effective psychological interventions into self-help
programs and delivering them as bibliotherapy, CD-ROMs or via the
Internet represents a major advance.
A recent review from the UK estimated that just under a quarter of
eating disorder sufferers receive any intervention at all and only 15%
receive psychological therapy (The Centre for Economic Performance's
Mental Health Policy Group, 2012). This intervention gap is particularly
large for bulimic disorders (Hoek, 2009). Cognitivebehavioral interventions for the treatment of bulimia nervosa and binge-eating disorder are
effective (Hay, Bacaltchuk, Stefano, & Kashyap, 2009). Self-help versions
of these interventions (which sometimes are guided, i.e., augmented
with a small amount of personal, telephone, or email contact with a
health care professional) can also be effective, at least for a subgroup of
participants (Perkins, Murphy, Schmidt, & Williams, 2006; Stefano,
Bacaltchuk, Blay, & Hay, 2006; Sysko & Walsh, 2008; Wilson, Vitousek,

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& Loeb, 2000; Wilson & Zandberg, 2012). Experts concluded that selfhelp is a robust means of improving implementation and scalability of
evidence-based treatment for eating disorders (Wilson & Zandberg,
2012, p. 343).
Despite such enthusiastic endorsement, both quantitative research on
self-help approaches for a range of mental disorders (e.g., Christensen,
Grifths, & Farrer, 2009; Eysenbach, 2005; Melville, Casey, & Kavanagh,
2010) and qualitative studies of self-help treatments capturing the
views of patients with eating disorders suggest that many patients struggle with adherence to these programs some because they feel shortchanged and see self-help as a cheap substitute for proper face-to-face
therapy, others because they nd it hard to motivate themselves to persist with working through the program with limited or no support
(McClay, Waters, McHale, Schmidt, & Williams, 2013; Murray et al.,
2003; Pretorius, Rowlands, Ringwood, & Schmidt, 2010; Snchez-Ortiz,
House, et al., 2011; Snchez-Ortiz, Munro, et al., 2011). The personal
costbenet-ratio for a certain intervention can be very different for
each patient. Interventions may not address symptoms that are a major
burden for patients, or the intervention itself may be experienced as a
burden. Low adherence in an intervention study can indicate that patients experience the intervention as either unpleasant or not helpful
(Rand & Sevick, 2000). Poor adherence may negatively affect intervention
outcome and a negative treatment experience may demoralize users and
reduce the likelihood of future help-seeking. While the traditional clinical trial and evidence-based medicine paradigm stipulates that high
dropout rates make trials less believable , for many eHealth trials,
in particular those conducted on the Internet and in particular with

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I. Beintner et al. / Clinical Psychology Review 34 (2014) 158176

self-help applications, high dropout rates may be a natural and typical


feature (Eysenbach, 2005). Yet, despite the importance of adherence,
its determinants and inuence on intervention effects have only been examined in a number of individual self-help trials (Carrard, Crepin, Rouget,
Lam, van der Linden, et al., 2011; Carrard, Fernandez-Aranda, et al., 2011;
Carter et al., 2003; Ghaderi, 2006; Ghaderi & Scott, 2003; Schmidt et al.,
2008; Thiels, Schmidt, Troop, Treasure, & Garthe, 2001; Troop, Schmidt,
Tiller, & Todd, 1996), but not been systematically reviewed across studies
and not been systematically linked to intervention outcomes. The present
paper aims to bridge this gap.
In the current review, we dene adherence in accordance with the
denition put forward by Haynes, Sackett, and Taylor (1979) as the extent to which the patient's behavior matches agreed recommendations
from the prescriber, thus (in contrast to compliance) emphasizing the
patient's freedom to decide to adhere to a recommendation (Horne,
Weinman, Barber, Elliott, & Morgan, 2005). For psychotherapeutic
approaches and other behavioral interventions (like self-help interventions) adherence is complex and difcult to dene. While in relation to
pharmacotherapy adherence commonly refers to whether the prescribed dosage of a medication is taken or not (Vitolins, Rand, Rapp,
Ribisl, & Sevick, 2000), in behavioral interventions there is dissent
about what best indicates adherence. Some authors argue that intervention efcacy is linked to session attendance or simply staying in the intervention long enough. These authors view intervention dropout as an
indicator of adherence (Edlund et al., 2002; Ogrodniczuk, Piper, & Joyce,
2006; Olfson et al., 2009). Others suggest that homework completion is
a better indicator of patient commitment and adherence (Scheel,
Hanson, & Razzhavaikina, 2004). Assessments of behavioral adherence
indicators (other than mere attendance of intervention sessions or
visited web-pages in an Internet-based intervention) often rely on patients' self-reports with their various sources of inaccuracy.
When looking at adherence in self-help interventions, we must
therefore deal with different denitions of adherence, different adherence measures, and differences in the precision of these measures.
Both providing and integrating this information will be a major challenge to this review, as it can be expected that the different denitions
and measures will lead to diverse results. Given these differences in definitions of adherence, we chose to look at and integrate any information
given about how patients participated in a study. We will use the word
participation as a broad term for measures of study and treatment dropout, adherence, and intervention completion.
In self-help interventions, several aspects of the intervention may inuence patients' participation: whether there is guidance or not, how
experienced the guide is with the target disorder, whether patients
can utilize the intervention at home or if they have to come to an institution, how much time the intervention will take, and whether there are
side effects from the intervention. Several characteristics of intervention
participants may also inuence adherence: how severe their illness is,
how they perceive their impairment, what benet they expect from
the intervention and what practical and emotional resources they
have. Patients' participation will not fully predict intervention outcome,
but it will probably be closely associated with intervention outcome.
The objectives of this systematic review are: (1) to identify measures
of patient participation reported in trials on manualized self-help
for bulimia nervosa and binge eating disorder1 and to integrate these

1
Two major reasons prevented us from including self-help interventions for AN in our
meta-analysis: 1. Compared with BN and BED, AN has a much higher potential for medical
complications. Accordingly, self-help in general does not seem to be an appropriate intervention for most individuals with AN. 2. To our knowledge, only two studies on self-help
interventions for AN have been conducted so far, both by Manfred Fichter and colleagues.
One intervention aimed at patients who had already been scheduled for inpatient treatment, and the main goal of the intervention was to reduce the length of the upcoming inpatient treatment (Fichter, Cebulla, Quadieg, & Naab, 2008). The other intervention was a
relapse prevention program for women who had completed inpatient treatment (Fichter
et al., 2012). In both cases, the interventions cannot be considered typical self-help interventions, (i.e., were not designed to be stand-alone treatments).

measures across different trials, (2) to determine whether and to what


degree differences in participation contribute to the moderation of
intervention outcomes. In order to do that, we need to identify moderators of participation, moderators of intervention outcomes, and examine if and how associations between those moderators and intervention
outcomes change when participation measures are taken into account.
2. Methods
2.1. Study selection
We performed a search on PubMed, PsychInfo, PsychArticles and
Web of Knowledge and considered all available manuscripts published
through July, 9th 2012. Search terms were: self-help and eating disorder, self-help and binge eating, self-help and bulimia nervosa; Internet
and eating disorder, Internet and binge eating, Internet and bulimia
nervosa, CD-ROM and eating disorder, CD-ROM and binge eating, and
CD-ROM and bulimia nervosa. Also, we examined the reference sections
of all identied articles, reviews and book chapters. We contacted corresponding authors of all relevant publications and asked for additional
unpublished data on published studies as well as unpublished studies.
Due to resource constraints, all searches were conducted by IB and we
limited our review to publications in English and German. We included
studies if they examined manualized self-help interventions (i.e., there
was an intervention book, a CD-ROM or an Internet program with subsequent sessions and pre-assigned contents, and the intervention program with reading assignments and behavioral exercises was the
same for each participant). We excluded studies on unstructured Internet forums or customized email-therapy. The intervention focus had to
be on modication of disordered eating; we therefore excluded studies
on behavioral weight loss interventions. Due to the limited number of
randomized controlled trials on manualized self-help interventions
with an untreated control group, we also included case series. We did
not require studies to have a minimal sample size.
For randomized controlled trials and controlled trials comparing
different types of self-help, we entered each trial condition separately
into the analyses. For randomized controlled trials and controlled trials
comparing self-help to an untreated control group or another active intervention (e.g., weight loss intervention, psychotherapy), we regarded
only data from the eating disorder specic self-help condition. The
design of the original studies (case series, RCT, CT) was included as a
potential moderator for participation and outcomes (see below).
2.2. Measures of participation
We examined different measures of participation as primary outcomes: (1) Study dropout rates were included as a very broad participation measure. (2) Intervention completion rates and proportions of
participants with high and low participation were included as more
specic participation measures. We calculated study dropout rates and
intervention completion rates based on intent-to-treat samples. We dened study dropout rate as the proportion of participants not available
for post-intervention assessments.2 We dened intervention completion rate as the proportion of participants who, according to the individual authors, completed the intervention irrespective of how it was
dened. We documented denitions of intervention completion by
individual authors (see Coding section). Furthermore, we recorded the
proportion of participants who completed less than half (low participation) or more than three-quarters (high participation) of the intervention when data were available in the original publications or could be
obtained from the authors. For trials with more than one self-help

2
Note that a participant might have completed the intervention, but not provided postintervention data and vice versa.

I. Beintner et al. / Clinical Psychology Review 34 (2014) 158176

intervention condition, the respective rates were calculated separately


for each condition.
2.3. Effect size calculation for intervention outcomes
We included studies for analyses of intervention effects if means and
standard deviations or other statistics allowing for effect size estimation
(e.g., median, quartiles, t-values) of core eating disorder outcomes
(frequencies of binge eating, eating disorder related attitudes) had
been reported. Measures for these outcomes had to be comparable
across studies: For frequencies of binge eating, the time span had to
be clearly specied in the paper; eating disorder related behaviors and
attitudes had to be assessed with standard (well-validated) measures.
For reasons of clarity and readability of this metaanalysis, we limited
outcome analyses to abstinence from binge eating, binge eating frequency, and subscales of the Eating Disorder Examination (EDE, EDE-Q).
Because the majority of trials did not include an untreated control
group, we calculated prepost-effect sizes only. For trials with more
than one self-help intervention condition, effect sizes were calculated
separately for each condition. To account for small sample sizes in
some of the trials, we calculated Hedges' g, which provides a better estimate of the population variance than Cohen's d (Hedges, 1981; Hedges
& Olkin, 1985). Mean differences were standardized by pooled standard
deviations (Hedges & Olkin, 1985) of pre- and post-intervention
measurements. An adjustment for sample size was conducted (Hedges
& Olkin, 1985). Whenever possible, we used data from intent-to-treat
analyses to calculate effect sizes. If only completer data were reported,
we rst calculated effect sizes based on these data and then adjusted
for the intent-to-treat sample, assuming an effect of zero for noncompleters (gITT = gcompleter Ncompleter NITT).
For three trials (Ruwaard et al., 2012; Traviss, Heywood-Everett, &
Hill, 2011; Treasure et al., 1994), several effect sizes had to be calculated
using median and quartile or range measures (Hedges & Olkin, 1985).
For one trial (Carter et al., 2003), effect sizes were recalculated from
t-values (Rosenthal, 1994). Authors of one trial (Mitchell et al., 2001) reported only the mean percentage decrease of binge eating and purging
compared with baseline. Post-intervention means and effect sizes were
calculated based on the baseline instead of the pooled SD for that trial.
We calculated rates of participants abstinent from binge eating if
denitions of abstinence and/or remission (especially the time span
covered) had been clearly specied in the original manuscripts. If necessary, we recalculated abstinence rates for the intent-to-treat samples;
therefore they may differ from abstinence rates reported in the original
manuscripts.
2.4. Coding
If a study included more than one self-help intervention condition,
each condition was coded separately. Information from all sections of
a research paper was included. All intervention conditions were coded
by IB according to the following characteristics.
2.4.1. Study participation and study outcomes
Study dropout rate. Rate of participants not attending post-intervention
assessments (based on intent-to-treat sample size of intervention
group). Some authors did not count participants who had been allocated to the intervention but never started it towards dropouts. If that was
the case, we added the proportion of patients who had not started intervention to the reported dropout rate.
Intervention completion rate. Rate of participants completing the intervention (based on intent-to-treat sample size of intervention group).
Denition of intervention completion. Denitions of intervention completion by authors of original manuscripts were categorized into four

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groups:(1) objective measure, high requirements, (2) objective measure, low requirements, (3) subjective measure, and (4) no denition
given. The intervention completion measure was deemed objective
when guidance session attendance or traceable participation in an
Internet-intervention was the relevant criterion. The intervention completion measure was deemed subjective when it relied solely on selfreport. Requirements were deemed high when intervention completion
implicated the attendance of a certain number of sessions or a certain
amount of traceable participation in an Internet-intervention. Requirements were deemed low when intervention completion just involved
staying in the intervention up to a certain time-point or attending postintervention assessment.
Low participation. Rate of participants who completed less than half of
the intervention based on the intent-to-treat sample size of the intervention group (this includes participants who never started the intervention after randomization).
High participation. Rate of participants who completed at least threequarters of the intervention based on the intent-to-treat sample size
of the intervention group.
Abstinence from binge eating. Abstinence rates calculated as specied
above.
Binge eating frequency, EDE-Q subscales. Effect sizes calculated as specied above.
2.4.2. Study and intervention characteristics
Design. (1) Randomized controlled trial (RCT), (2) controlled trial (CT),
and (3) case series.
Sample size. Number of participants in the intervention condition.
Intervention type. (1) Bibliotherapy, (2) CD-ROM intervention, and
(3) Internet intervention.
Guidance. (1) Unguided self-help, and (2) guided self-help.
Guides' qualication. Qualication of guidance provider: (1) nonspecialist (GP, nurse, social worker3), (2) mental health specialist
(e.g., psychiatrist, psychologist, psychology student), or (3) ED or
CBT specialist.
Duration of the intervention period. Number of weeks between baseline
and post-assessment.
Number of session/modules in guided self-help. Number of guidance sessions (for bibliotherapy) or number of subsequent modules with therapist feedback (for CD-ROM and Internet-based programs).
Medication. Medication administered in addition to self-help
intervention: (0) none, (1) placebo, (2) Fluoxetine, or (3) Orlistat.
Quality of diagnoses. (1) Clinical assessment, (2) standardized selfreport questionnaire, and (3) standardized or structured interview.
Quality of study. (1) High quality of study (this was assumed if the study
was a RCT, participants were diagnosed with a standardized or

3
In two trials conducted in the UK (Cooper, Coker, & Fleming, 1994; Cooper et al.,
1996), guidance was provided by a social worker. In the UK, social workers need to complete additional training to become Approved Mental Health Professionals. Since no information was given on if the social worker engaged in both of the studies had completed this
training, we classied him as a non-specialist.

162

I. Beintner et al. / Clinical Psychology Review 34 (2014) 158176

structured interview, authors gave a denition of intervention completion, and the sample size was sufcient to detect a medium effect for
continuous outcomes in a repeated measures ANOVA (N = 36 based
on a power calculation, Mayr, Erdfelder, Buchner, & Faul, 2007)), and
(2) low quality of study.
2.4.3. Patient characteristics
For one trial (Furber, Steele, & Wade, 2004), pre-intervention data
were reported separately for completers and dropouts. Here, we
recalculated pre-intervention means (MITT = (Ncompleter Mcompleter +
Ndropout Mdropout) NITT) and standard deviations (SDpooled, Hedges
& Olkin, 1985) for the intent-to-treat sample.
Diagnoses. (1) Bulimia nervosa (BN) or eating disorder not otherwise
specied, BN subtype (EDNOS-BN), (2) Binge eating disorder (BED),
and (3) mixed.
Mean baseline number of binge eating episodes. Mean number of binge
eating episodes during the past 28 days reported by participants in
the intervention group at baseline.
Mean baseline EDE-Q scores. Mean scores of EDE-Q subscales Restraint,
Eating concern, Weight concern, and Shape concern of the intervention
group at baseline.
Mean age. Mean age of participants in the intervention group.
Mean baseline BMI. Mean BMI of participants in the intervention group
at baseline.
2.5. Integration of outcomes
We conducted all analyses using IBM SPSS Statistics Version 19 and
21 in combination with SPSS macros to perform meta-analytic analyses
(Lipsey & Wilson, 2000; Wilson, 2005). We integrated event rates using
a meta-analytic model for point estimates of single groups (Einarson,
1997). The inverse variances of proportions (s2 = p (1 p) n)
(Fleiss, 1981) were used as weights. We added a score of 0.005 to
event rates of zero to permit the calculation of a weight (Sheehe,
1966). Overall heterogeneity across studies was tested using the
Q-test (Hedges & Olkin, 1985). Analyses were based on the random
effects model (Hedges & Olkin, 1985). The random variance component
was estimated by a restricted maximum likelihood approach.
2.6. Moderator analyses
To identify factors that may impact both intervention participation
and outcomes, we conducted moderator analyses. We included both
study/intervention and patient characteristics as described above as
potential moderators. To be included in the moderator analysis, data
from at least 10 studies had to be available to ensure a minimum of
power to detect moderator effects (Borenstein, Hedges, Higgins, &
Rothstein, 2011).
We performed meta-regression analyses as moderator analyses
(Hedges & Olkin, 1985). All categorial independent variables were
transformed into dummy variables. To facilitate interpretation of ndings, all independent variables were centered around their median
(Kraemer & Blasey, 2004). Primary analyses were based on the random
effects models. However, here the power to detect relationships between moderators and intervention effects is often low (Borenstein
et al., 2011). The xed effects model, on the other hand, yields more
statistical power than the random effects model, yet generalizability is
limited (Rosenthal, 1995). We therefore performed secondary analyses
based on the xed effects model to detect moderators that might have
an impact, but may not have been detected in the random effects
model due to lack of statistical power. When analyzing moderators of

intervention completion rates, denition of intervention completion


(see above) was entered as a covariate in all analyses.
2.7. Sensitivity analyses
Analyses of intervention effect moderators were rst performed unadjusted as described above. Since intervention effects are unlikely to be
independent from dropout rates and intervention completion rates, we
repeated all analyses by (1) adjusting for dropout rates and the statistical interaction between moderators and dropout rates and (2) adjusting
for intervention completion rates, the statistical interaction between
moderators and intervention completion rates and intervention completion denitions. It is likely that moderator analyses for treatment effect sizes based on intent-to-treat samples will lead to very different
results depending on whether we adjust for study dropout or treatment
completion rates or not. When analyses are not adjusted, we might mistake differences in treatment outcome that are solely due to differences
in dropout or treatment completion rates for true differences in treatment efcacy. On the other hand, we might miss true differences that
are masked by differences in dropout or treatment completion rates.
Adjusting for dropout or treatment completion rates will both increase
statistical power to detect true differences, and let associations that are
probably statistical artifacts disappear. A participation outcome was
deemed predicted robustly if analyses in both the xed and random
effects models yielded signicant or almost signicant associations. An
intervention effect was deemed predicted robustly if at least analyses
in both the xed and random effects model adjusted for study dropout
rates or in both the xed and random effects model adjusted for intervention completion rates and intervention completion denitions
yielded signicant or almost signicant associations.
We performed sensitivity analyses excluding interventions that
augmented self-help with pharmacotherapy or a placebo medication.
Outliers of participation indicators (dropout rates, intervention completion rates, low and high participation rates) and intervention outcomes
were identied by visual inspection of boxplots. Analyses were then repeated with outliers excluded. We limited those secondary sensitivity
analyses to the unadjusted analyses.
3. Results
3.1. Sample of studies
Fig. 1 shows the QUOROM diagram of study selection. Of the identied trials we excluded one study because the intervention consisted of
monthly self-help letters and was deemed difcult to t into any of the

Fig. 1. QUOROM statement ow diagram.

I. Beintner et al. / Clinical Psychology Review 34 (2014) 158176

abovementioned coding categories (Huon, 1985). Another study was


excluded because authors solely analyzed factors inuencing failure to
engage in a self-help program (Bell & Newns, 2004). In one publication,
preliminary data from an ongoing study were reported (Bell & Hodder,
2001), while nal results have never been published. We therefore
excluded the preliminary data from the analyses. Another trial was
excluded because the intervention examined non-manualized email
therapy (Robinson & Serfaty, 2008). Several publications exist on results
of a multicenter study on the effectiveness of an Internet-based intervention for the complete sample as well as for subsamples
(SALUT, (Carrard, Fernandez-Aranda, et al., 2011; Carrard et al., 2006;
Fernandez-Aranada et al., 2008, 2009; Liwowsky, Cebulla, & Fichter,
2006; Nevonen, Mark, Levin, Lindstrom, & Paulson-Karlsson, 2006)).
In our review we included only data from the full sample (Carrard,
Fernandez-Aranda, et al., 2011).
Overall, 73 different publications reporting on 50 different trials on
self-help and Internet-based interventions for binge eating and bulimia
nervosa including a total of 2586 participants could be identied (see
Appendix A, Table A.1). 34 trials were (R)CTs of which 13 included a
non-intervention waitlist control group. In the other (R)CTs, different
types of interventions were compared. Twelve of the identied 50 trials
examined two self-help interventions. Sixty-two different intervention
conditions are included in the analyses: 45 conditions from RCTs, 16
conditions from case series, and one condition from a controlled trial.
The duration of the self-help interventions in those 62 conditions
ranged between 6 and 26 weeks (median: 12.5 weeks). In 50 conditions, participants received bibliotherapy, in 6 conditions they received
a CD-ROM-based intervention and in 6 conditions they received an
Internet-based intervention. In two conditions, self-help was accompanied by medication with Fluoxetine, in one by Orlistat, and in three conditions by a placebo medication. In 9 of the remaining 55 intervention
conditions, participants on antidepressants were explicitly excluded
from the studies; in the remaining 46 conditions, patients were either
included provided their dosage had been stable for a certain amount
of time, or authors did not report any inclusion or exclusion criteria
regarding antidepressants. In 43 intervention conditions, participants
received some kind of guidance, and in 19 conditions, participants received no guidance.
The denition of intervention completion varies considerably between studies. In 18 conditions, intervention completion was dened
objectively and requirements were high, in 9 conditions, intervention
completion was dened objectively but requirements were low. In 12
conditions, intervention completion was dened subjectively, and in
11 conditions authors did not specify their criteria for intervention completion at all.
Seven studies including 8 of the 62 conditions met the criteria for
high quality of study (RCT, participants diagnosed with a standardized
or structured interview, specic denition of intervention completion,
and sufcient sample size to detect a medium effect in a repeated measures ANOVA; Bailer et al., 2004; Cassin, 2008; Ljotsson et al., 2007;
Mitchell et al., 2011; Snchez-Ortiz, House, et al., 2011; Snchez-Ortiz,
Munro, et al., 2011; Schmidt et al., 2007; Striegel-Moore et al., 2010).
Intervention was provided for patients with bulimia nervosa (BN) or
sub-threshold bulimia in 33 conditions, for patients with binge eating
disorder (BED) in 15 conditions, and for both BN and BED patients in
14 conditions. Diagnoses were made by standardized or structured interviews in 36 conditions, by a standardized questionnaire in 6 conditions and by clinical assessment in 5 conditions. Means of diagnostic
assessments were not reported for 5 conditions. Mean age of participants ranged from 17.4 to 50.3 years (k = 57; median: 29.5 years),
mean body mass index (BMI) from 20.0 to 39.6 kg/m2 (k = 49; median:
24.5 kg/m2). Mean baseline binge eating frequency ranged from 10 to
36 binge eating episodes in the past 28 days (k = 41; median: 17.6
episodes). Mean baseline EDE(-Q) Restraint score ranged from 1.6 to
5.3 (k = 29; median 3.1); mean baseline EDE(-Q) Eating Concern
score ranged from 1.9 to 4.5 (k = 25; median 3.4); mean baseline

163

EDE(-Q) Weight Concern score ranged from 3.1 to 5.2 (k = 27; median
4.2); and mean baseline EDE(-Q) Shape Concern score ranged from 3.4
to 5.4 (k = 28; median 4.5). Samples of studies recruiting BN patients
had substantially higher mean baseline EDE(-Q) Restraint scores,
lower mean BMIs, and involved younger patients than samples of studies recruiting BED patients (details available upon request).
3.2. Participation
Rates of study dropout, intervention completion, low participation
and high participation are substantially heterogeneous; we therefore abstain from reporting overall mean rates. Between 1% and 88% of participants dropped out of the study (k = 51; median: 25%). Between 6%
and 86% of participants completed the intervention (k = 51; median:
59%). Between 20% and 81% of participants were high participators
(i.e., they completed at least three-quarters of the assigned intervention;
k = 11; median: 41%). Between 17% and 58% of participants were low
participators, (i.e., they completed less than half of the assigned intervention; k = 13; median: 38%). Table A.2 shows study dropout, intervention
completion, low participation and high participation rates for individual
studies as well as results of the Q-Test for heterogeneity.
3.3. Moderators of participation
Table 1 illustrates the prediction of participation by study and intervention characteristics. Table 2 illustrates the prediction of participation
by patient characteristics. In Appendix C (Table C.1), we report additional results of Q-Test subgroup analyses for categorial moderators.
In what follows, we will summarize signicant results of random effects
model analyses in detail and also briey report signicant results from
xed effects model analyses of study/intervention and patient moderators of the different parameters of participation. If a categorial moderator signicantly predicts participation in the unadjusted random effects
model, we report overall subgroup effects and condence intervals to
illustrate differences between groups.
3.3.1. Study dropout rate
Intervention type signicantly predicts study dropout rates in the
random effects model. The overall study dropout rate is highest in CDROM interventions (30%; 95% CI: 1346%) followed by bibliotherapy
(29%; 95% CI: 2435%) and Internet-based interventions (16%; 95% CI:
329%). In addition, design, guidance, the guides' qualication, and the
duration of the intervention signicantly predict study dropout rates
in the xed effects model (see Tables 1 and C.1).
Diagnoses of participants, mean EDE(-Q) Restraint score, and mean
body mass index (BMI) in the intervention group at baseline signicantly
predict study dropout rates in the random effects model. The overall study
dropout rate is highest in studies with both bulimia nervosa (BN) and
binge eating disorder (BED) patients (35%; 95% CI: 2644%) followed by
studies with BN patients (29%; 95% CI: 2335%) and studies with BED patients (14%; 95% CI: 524%). A higher score on the EDE(-Q) Restraint scale
and a lower BMI at baseline are associated with a higher study dropout
rate. In addition, mean number of binge eating episodes in the past
4 weeks, mean EDE(-Q) Eating Concern, Weight Concern and Shape Concern scores, and mean age in the intervention group at baseline signicantly predict study dropout rates in the xed effects model (see Table 2).
3.3.2. Intervention completion rate
We entered the denitions of intervention completion (objective,
high requirements vs. objective, low requirements vs. subjective vs.
not specied) as described in the Methods section as a covariate in all
analyses. Therefore we cannot provide overall intervention completion
rates for subgroups to illustrate results of categorial moderators.
None of the study and intervention characteristics predict intervention completion rates in the random effects model. In the xed effects
model, design, intervention type, guidance, the guides' qualication

164

Table 1
Results of metaregression analyses for potential moderators of study dropout and intervention completion: study and intervention characteristics.
Measure
Potential moderators

Intervention type (book vs. CD-ROM vs. Internet)

Guidance (unguided self-help vs. guided self-help (GSH))

Qualication of guide (GSH only) basic vs. medium vs. higha

Number of sessions/modules (GSH only)

Duration of the intervention (weeks)

Intervention completion rate (by Author denition)


(Adjusted for intervention completion denition;
see Methods section for further detail)

Rate of participants who completed


at least 75% of intervention

Rate of participants who


completed less than 50%
of intervention

k
FEM

50
bcase series = .1522***

51
bCT = .1378**

13
n.s.

REM
k
FEM

n.s.
50
bCD-ROM = .1320***

REM

bInternet = .1371 p = .0590

n.s.
51
bCD-ROM = .1472***
bInternet = .1859***
n.s.

k
FEM
REM
k
FEM

50
bGSH = .1658***
n.s.
35
bmedium = .1007**
bhigh = .1308***
n.s.
40
n.s.
n.s.
48
b = .0084***
n.s.

10
bCT = .2858***
bcase series = .2896***
bcase series = .2078 p = .0727
10
bCD-ROM = .3001***
bInternet = .3332***
bCD-ROM = .2643**
bInternet = .2799**
10
bGSH = .1592*
n.s.
9

REM
k
FEM
REM
k
FEM
REM

51
bGSH = .1342***
n.s.
38
bhigh = .1807***
bhigh = .2045 p = .0587
40
n.s.
n.s.
49
b = .0063**
n.s.

FEM: xed effects model; REM: random effects model; b: linear regression slope. See end of Table 2 for guidance on reading these results. *pb .05, **pb .01, ***pb .001.
a
Basic: non-specialist, medium: non-specialist mental health professional, high: ED or CBT specialist.

10
n.s.
n.s.
10
b = .0099*
n.s.

n.s.
13
n.s.
n.s.
13
bGSH = .1598**
bGSH = .1666*
11
bmedium = .1141*
n.s.
12
n.s.
n.s.
13
b = .0093*
n.s.

I. Beintner et al. / Clinical Psychology Review 34 (2014) 158176

Design (RCT vs. CT vs. case series; no data on CTs available)

Study dropout rate

I. Beintner et al. / Clinical Psychology Review 34 (2014) 158176

165

Table 2
Results of metaregression analyses for potential moderators of study dropout and intervention completion: patient characteristics.
Outcome measure
Potential moderators

Diagnoses
(BED vs. BN vs. mixed)

Baseline 4 week binge eating


frequency
Baseline EDE-Q Restraint

Baseline EDE-Q Eating Concern

Baseline EDE-Q Weight Concern

Baseline EDE-Q Shape Concern

Age

BMI

k
FEM
REM
k
FEM
REM
k
FEM
REM
k
FEM
REM
k
FEM
REM
k
FEM
REM
k
FEM
REM
k
FEM
REM

Study dropout rate

Intervention completion rate (by Author denition)


(Controlled for intervention completion denition;
coding: (1) objective, high requirements vs. (2) objective,
low requirements vs. (3) subjective vs. (4) not specied;
see Methods section for further detail)

Rate of participants who


completed at least 75%
of intervention

Rate of participants who


completed less than 50%
of intervention

50
bBED = .2473***
bBN = .0531**
bBED = .2042**
31
b = .0045*a
n.s.
23
b = .2015***
b = .1620**a
20
b = .1103***
n.s.
21
b = .0749**
n.s.
22
b = .1331***
n.s.
47
b = .0114***
b = .0062 p = .0752
40
b = .0219***
b = .0156**

51
bBED = .0721*
bBN = .0591*
n.s.
35
n.s.a
n.s.
25
n.s.
n.s.
22
n.s.a
n.s.
23
n.s.
n.s.
24
b = .1307**
n.s.
49
n.s.
n.s.
44
b = .0086**
n.s.

10
bBED = .1237*
bBN = .2975***
n.s.
4

13
bBN = .1759**
bBN = .1726**
6

12
b = .0132**
b = .0134**
12
b = .0191**
b = .0190**

9
b

FEM: xed effects model; REM: random effects model; b: linear regression slope. See Results section for further details. *pb .05, **pb .01, ***pb .001.
How to read Tables 1 and 2:
Study dropout and intervention completion rates were coded using values between 0 and 1. For categorial moderators with two subgroups, b is the difference between the two groups. The
reference group is indicated in the subscript. For categorial moderators with three subgroups, b is the difference between one group and the other two groups. The reference group is
indicated in the subscript. For continuous moderators, b indicates the change in effect sizes if the value of the moderator is increased by one unit.
a
Substantial changes of results in sensitivity analyses.
b
No analyses conducted due to small number of studies.

and the duration of the intervention signicantly predict intervention


completion rates (see Table 1).
None of the patient characteristics predict intervention completion
rates in the random effects model. In the xed effects model, diagnoses
of participants, mean EDE(-Q) Shape Concern scores, and mean BMI in
the intervention group at baseline signicantly predict intervention
completion rates (see Table 2).
3.3.3. High participation
Intervention type signicantly predicts high participation rates
(i.e., the proportion of participants who completed more than three
quarters of the intervention) in the random effects model. The overall
proportion of patients with high participation is highest in bibliotherapy (65%; 95% CI: 5475%) followed by CD-ROM interventions
(38%; 95% CI: 2254%) and Internet-based interventions (37%; 95%
CI: 2054%). In addition, design, guidance and duration of the intervention signicantly predict high participation rates in the xed
effects model (see Tables 1 and C.1).
None of the patient characteristics predict high participation rates in
the random effects model. In the xed effects model, diagnoses of participants signicantly predict high participation rates (see Tables 2 and
C.1).
3.3.4. Low participation
Guidance signicantly predicts low participation rates (i.e., the
proportion of participants who completed less than half of the intervention) in the random effects model. The overall proportion of patients
with low participation was higher in unguided self-help (52%; 95%
CI: 3866%) than in guided self-help (35%; 95% CI: 2942%). In addition,
the guides' qualication and the duration of the intervention signicantly

predict low participation rates in the xed effects model (see Tables 1
and C.1).
Diagnoses of participants, mean age, and mean BMI in the intervention group at baseline signicantly predict low participation rates in the
random effects model. The overall proportion of patients with low participation is highest in studies with BN patients (43%; 95% CI: 3848%)
followed by studies with both BN and BED patients (26%; 95% CI:
1537%) and studies with BED patients (22%; 95% CI: 637%). A lower
age and a lower BMI are associated with a higher proportion of patients
with low participation. No additional patient moderators signicantly
predict low participation rates in the xed effects model.

3.4. Intervention outcomes


Mean effect sizes for all analyzed outcomes were substantially heterogeneous and we therefore abstain from reporting mean overall effect
sizes across trials. Effect sizes for the frequency of binge eating episodes
range from g = .03 to g = 2.68 (k = 48; median: .68). Between 9% and
64% of participants had achieved abstinence from binge eating at postintervention assessment (k = 32; median: 29.8%). Effect sizes for the
EDE(-Q) Restraint scale range from g = .22 to g = 1.18 (k = 29;
median: .44). Effect sizes for the EDE(-Q) Eating Concern scale range
from g = .11 to g = 1.63 (k = 26; median: .85). Effect sizes for
the EDE(-Q) Weight Concern scale range from g = .05 to g = 1.20
(k = 27; median: .70). Effect sizes for the EDE(-Q) Shape Concern
scale range from g = .01 to g = 1.27 (k = 28; median: .75). Table A.3
shows abstinence rates and effect sizes for individual studies as well
as results of the Q-Test for heterogeneity. Appendix B shows forest
plots of individual effect sizes and condence intervals.

166

Table 3
Results of metaregression analyses for potential intervention effect moderators: study and intervention characteristics.
Outcome measures
Potential moderator

4 week binge eating


frequency
k

Design (RCT vs. case series)

Intervention type (bibliotherapy


vs. CD-ROM vs. Internet)

Qualication of guide (GSH only)


basic vs. medium vs. highc

Number of sessions/modules
(GSH only)

Duration of the intervention


(weeks)

FEM
adj. dropout
adj. intervention completion
REM
adj. dropout
adj. intervention completion
FEM

48
41
40
48
41
40
48

bcase series = .1215*b


n.s.
n.s.
n.s.
n.s.
n.s.
bCD-ROM = .2692*

31
26
29
31
26
29
31

adj. dropouta
adj. intervention completiona
REM
adj. dropouta
adj. intervention completiona
FEM
adj. dropout
adj. intervention completion
REM
adj. dropout
adj. intervention completion
FEM
adj. dropout

41
40
41
40
48
41
40
48
41
40
33
29

n.s.
bInternet = .4787**
n.s.
n.s.
bInternet = .4871 p = .0662
n.s.b
bGSH = .1912**
bGSH = .2744**
n.s.
n.s.
bGSH = .2524p = .0846
bmedium = .1858*
n.s.

adj. intervention completion

30

REM
adj. dropout
adj. intervention completion
FEM
adj. dropout
adj. intervention completion
REM
adj. dropout
adj. intervention completion
FEM
adj. dropout
adj. intervention completion
REM
adj. dropout
adj. intervention completion

EDE(-Q) Eating
Concerna
k

EDE(-Q) Weight
Concerna
k

EDE(-Q) Shape
Concerna
k

29
24
26
29
24
26
29

n.s.
n.s.
n.s.
n.s.
n.s.
n.s.
n.s.

26
21
23
26
21
23
26

bcase series = .2700**


n.s.
n.s.
n.s.
n.s.
n.s.
n.s.

27
22
24
27
22
24
27

n.s.
n.s.
n.s.
n.s.
n.s.
n.s.
n.s.

28
23
25
28
23
25
28

n.s.
bcase series = .2922*
n.s.
n.s.
n.s.
n.s.
bInternet = .2553*

26
29
31
26
29
31
26
29
31
26
29
22
18

bcase series = .0885**


n.s.
bcase series = .0986**
n.s.
n.s.
n.s.
bCD-ROM = .1815***
bInternet = .1020*
n.s.
bInternet = .1382*
bCD-ROM = .2174*
n.s.
n.s.
bGSH = .2088***
bGSH = .1833***
bGSH = .2026***
bGSH = .1960**
bGSH = .1772**
bGSH = .1936**
bmedium = .1069*
n.s.

24
26
29
24
26
29
24
26
29
24
26
23
19

21
23
26
21
23
26
21
23
26
21
23
20
16

n.s.
n.s.
n.s.
n.s.
n.s.
bGSH = .4008***
bGSH = .5865***
bGSH = .6717**
n.s.
bGSH = .4899**
bGSH = .6287 p = .0545
bhigh = .4100*
n.s.

22
24
27
22
24
27
22
24
27
22
24
21
17

n.s.
n.s.
n.s.
n.s.
n.s.
bGSH = .3023**
bGSH = .4581***
n.s.
n.s.
bGSH = .4279**
n.s.
n.s.
n.s.

23
25
28
23
25
28
23
25
28
23
25
22
18

n.s.
n.s.
n.s.
n.s.
n.s.
bGSH =
bGSH =
bGSH =
bGSH =
bGSH =
n.s.
n.s.
n.s.

31

n.s.

21

18

bhigh = .5529**

19

22
18
31

n.s.
n.s.
n.s.

23
19
21

n.s.
n.s.
bmedium = .5415*

20
16
18

n.s.
n.s.
n.s.

21
17
19

34
30
31
34
30
31
46
39
38
46
39
38

n.s.
n.s.
n.s.
n.s.
n.s.
n.s.
n.s.
n.s.
n.s.
n.s.
n.s.
n.s.

23
19
28
23
19
28
30
25
28
30
25
28

n.s.
n.s.
b = .0249**
n.s.b
n.s.
b = .0222 p = .0755
b = .0054*
b = .0067**
n.s.
n.s.
n.s.
n.s.

23
19
21
23
19
21
27
22
24
27
22
24

b = .0666**
n.s.
b = .1954***
n.s.
n.s.
b = .1961**
b = .0159*
b = .0184*
b = .0505**
n.s.
n.s.
n.s.

20
16
18
20
16
18
24
19
21
24
19
21

b = .0661**
n.s.
b = .1004*
n.s.
n.s.
n.s.
b = .0527***
b = .0295**
n.s.
b = .0507*
n.s.
n.s.

21
17
19
21
17
19
25
20
22
25
20
22

bhigh =
.5925 p = .0626
n.s.
n.s.
bhigh =
.5925 p = .0626
b = .0625***
b = .0450**
b = .0724*
b = .0604*
b = .0450**
b = .0697 p = .0779
n.s.
n.s.
n.s.
n.s.
n.s.
n.s.

20

33
29
30

bmedium = .6446***
bhigh = .5258**
bmedium = .4799p = .0691
n.s.
bmedium = .5987*

n.s.
bInternet = .6944**
n.s.
n.s.
bInternet = .7169*
bGSH = .2524**
bGSH = .3295**
bGSH = .4714*
n.s.
n.s.
n.s.
n.s.
bmedium = .3559*
bhigh = .6242**
bmedium = .4844**

bmedium = .5652*
bhigh = 1.0146**
n.s.
n.s.
bmedium = .5652*
bhigh = 1.0146**
b = .0617***
b = .0509**
b = .0579*
b = .0573*
b = .0509**
n.s.
n.s.
n.s.
n.s.
n.s.
n.s.
n.s.

22
18
20
22
18
20
22
18
20
26
21
23
26
21
23

.3599**
.4873***
.4471*
.3051p = .0592
.4498**

FEM: xed effects model; REM: random effects model; b: linear regression slope; adj. dropout: metaregression analyses adjusted for dropout rates; adj. intervention completion: metaregression analyses adjusted for intervention completion rates. See
end of Table 4 for guidance on reading these results. *pb .05, **pb .01, ***pb .001.
a
No data on CD-ROM conditions available.
b
Substantial changes of results in sensitivity analyses, see results section for further details.
c
Basic: GP, nurse, social worker, medium: non-specialist mental health professional, high: ED or CBT specialist.

I. Beintner et al. / Clinical Psychology Review 34 (2014) 158176

Guidance (unguided self-help


vs. guided self-help (GSH))

EDE(-Q) Restrainta

Abstinence from binge


eating

I. Beintner et al. / Clinical Psychology Review 34 (2014) 158176

3.5. Moderators of intervention outcomes across trials


Table 3 illustrates the prediction of intervention outcomes by study
and intervention characteristics. Table 4 illustrates the prediction of
intervention outcomes by patient characteristics. Analyses were rst
performed unadjusted, then repeated separately adjusting for dropout
rates, and adjusting for intervention completion rates and intervention
completion denitions. Both tables provide an overview of results depending on what type of analysis was performed, and how different
moderators predict different outcomes. A guide to reading Tables 3
and 4 is provided at the end of Table 4. In Appendix C (Table C.2), we
report additional results of Q-Test subgroup analyses for categorial
moderators. Subsequently, we will summarize signicant results of unadjusted and adjusted random effects model analyses in detail and also
briey report signicant results from xed effects model analyses of
study/intervention and patient moderators of the different outcomes.
If a categorial moderator signicantly predicts an intervention outcome in the unadjusted random effects model, we report overall subgroup effects and condence intervals to illustrate differences between
groups.
3.5.1. Study and intervention characteristics
Design does not predict intervention effects in the random effects
model. It predicts effect sizes for the frequency of binge eating episodes,
abstinence from binge eating, and effect sizes for the EDE(-Q) Eating
Concern and Shape Concern scales in the xed effects model (see
Tables 3 and C.2). All results are consistent.
Intervention type predicts abstinence from binge eating and effect
sizes for the EDE(-Q) Restraint scale in the random effects model. Abstinence rates are highest for Internet-based interventions (38%; 95%
CI: 2055%) followed by bibliotherapy (31%; 95% CI: 2536%) and
CD-ROM interventions (9%; 95% CI: 1028%) in the unadjusted
random effects model. Effect sizes for the EDE(-Q) Restraint Scale are
higher in Internet-based interventions than in bibliotherapy in the random effects model adjusted for intervention completion rates and intervention completion denitions. In addition, intervention type predicts
effect sizes for the frequency of binge eating episodes and for the
EDE(-Q) Shape Concern scale in the xed effects model (see Tables 3
and C.2). All results are consistent.
Guidance predicts abstinence from binge eating, effect sizes for the
EDE(-Q) Eating Concern, Weight Concern and Shape Concern scales in
the random effects model. More patients in guided self-help were abstinent from binge eating (35%; 95% CI: 3041%) compared with unguided
self-help (16%; 95% CI: 724%) in the unadjusted and both the adjusted
random effects models. Guided self-help yields larger effect sizes for the
EDE(-Q) Eating Concerns scale than unguided self-help in both the
adjusted random effects models. Guided self-help yields larger effect
sizes for the EDE(-Q) Weight Concerns scale than unguided self-help
in the random effects model adjusted for dropout rates. Effect sizes for
the EDE( Q) Shape Concern scale are medium to large in guided
self-help (g = .79; 95% CI: .65.93) and small to medium in unguided
self-help (g = .48; 95% CI: .20.77) in the unadjusted random effects
model. Guided self-help yields larger effect sizes for the EDE(-Q) Shape
Concerns scale than unguided self-help in the random effects model
adjusted for dropout rates.
In addition, guidance predicts effect sizes for the frequency of binge
eating episodes and the EDE(-Q) Restraint scale in the xed effects model
(see Tables 3 and C.2). All results are consistent.
The guides' qualication in guided self-help predicts effect sizes for the
frequency of binge eating, the EDE(-Q) Restraint, and Shape Concern
scales in the random effects model. Effect sizes for the frequency of
binge eating episodes are medium to large in interventions guided by
ED or CBT specialists (g = .68; 95% CI: .211.16), large in interventions
guided by other mental health specialists (g = 1.01; 95% CI: .781.24),
and medium in interventions guided by non-specialists (g = .49; 95%
CI: .030.94) in the unadjusted random effects model, while variations

167

are greatest in interventions guided by non-specialists. Effect sizes are


also larger in interventions guided by specialists than in interventions
guided by non-specialists in the random effects model adjusted for intervention completion rates and intervention completion denitions.
Effect sizes for the EDE(-Q) Restraint Scale were larger in interventions
guided by non-specialists than in interventions guided by ED or CBT
specialists or guided by other mental health specialists in the random
effects model adjusted for intervention completion rates and intervention completion denitions. Effect sizes for the EDE(-Q) Shape Concern
scale are larger in interventions guided by ED or CBT specialists than in
interventions guided by other mental health specialists and interventions guided by non-specialists in the random effects model adjusted
for intervention completion rates and intervention completion denitions. In addition, the guides' qualication predicts abstinence from
binge eating and EDE(-Q) Eating and Weight Concern in the xed effects
model (see Tables 3 and C.2). All results are consistent.
The number of sessions or modules in guided self-help predicts abstinence from binge eating and effect sizes for the EDE(-Q) Restraint,
Weight Concern and Shape Concern scales in the random effects model.
Abstinence rates are higher in interventions with more sessions/
modules in the random model adjusted for intervention completion
rates and intervention completion denition. Interventions with more
sessions yield larger effect sizes for the EDE(-Q) Restraint scale in the
random effects model adjusted for intervention completion rates and intervention completion denitions. Interventions with more sessions
yield larger effect sizes for the EDE(-Q) Weight Concern scale in all
models. Interventions with more sessions yield larger effects sizes for
the EDE(-Q) Shape Concern scale in both the unadjusted random effects
model and the random effects model adjusted for dropout rates. In addition, the number of sessions or modules in guided self-help predicts effect sizes for the EDE(-Q) Eating Concern scale in the xed effects model
(see Table 3). All results are consistent.
The duration of the intervention predicts effect sizes for the EDE(Q)
Eating Concern scale in the random effects model. Longer interventions
yield smaller effect sizes for the EDE(Q) Eating Concerns scale in the
unadjusted random effects model. In addition, the duration of the intervention predicts abstinence from binge eating and effect sizes for the
EDE(Q) Restraint scale in the xed effects model (see Table 3).

3.5.2. Patient characteristics


Diagnoses of participants signicantly predict effect sizes for the frequency of binge eating episodes, abstinence from binge eating, and effects sizes for the EDE(-Q) Eating, Weight and Shape Concern scales in
the random effects model. Effect sizes for the frequency of binge eating
are large in studies with BED patients (g = 1.19; 95% CI: .931.45),
medium to large in studies with BN patients (g = .75; 95% CI: .55.94)
and small to medium in studies with both BN and BED patients (g =
.50; 95% CI: .19.80) in the unadjusted random effects model. In the random effects model adjusted for intervention completion rates and intervention completion denitions, studies with BN patients yield lower
abstinence rates than studies with BED patients and both BN and BED
patients. Effect sizes for the EDE(-Q) Eating Concern scale are large for
studies with BED patients (g = 1.28; 95% CI: 1.001.56), medium to
large for studies with BN patients (g = .68; 95% CI: .39.96), and small
to medium for studies with both BN and BED patients (g = .53; 95%
CI: .27.79) in the unadjusted random effects model. Effect sizes for the
EDE(-Q) Weight Concern scale are medium to large for studies with
BED patients (g = .93; 95% CI: .721.14) and studies with BN patients
(g = .68; 95% CI: .48.88) and small to medium for studies with both
BN and BED patients (g = .48; 95% CI: .29.67) in the unadjusted random effects model. Effect size EDE(-Q) Shape Concern is large for studies
with BED patients (g = 1.01; 95% CI: .821.20), medium to large for
studies with BN patients (g = .71; 95% CI: .52.90) and small to medium
for studies with both BN and BED patients (g = .47; 95% CI: .30.66)
in the unadjusted random effects model. In addition, diagnoses of

168

Outcome measure
Potential moderators

4 week binge eating


frequency
k

Diagnoses (BED vs. BN vs. mixed)

Baseline 4 week binge eating


frequency

Baseline EDE-Q Restraint

Baseline EDE-Q Eating Concern

Abstinence from binge


eating
k

EDE(-Q) Restraint
k

EDE(-Q) Eating
Concern
k

EDE(-Q) Weight
Concern
k

31

bBED = .0844**

29

bBN = .2227**

26

bBED = .8198*

27

41
40

bBED = .7006***
bBN = .1374*
bBED = .2896*
bBED = .3276*

26
29

24
26

bBN = .2981**
bBED = .4803**

21
23

bBED = 1.2998**
n.s.

REM

48

bBED = .6946**

31

bBED = .1351**
bBED = .1152*
bBN = .1673**
n.s.

29

n.s.

26

adj. dropout
adj. intervention completion
FEM
adj. dropout
adj. intervention completion
REM
adj. dropout
adj. intervention completion
FEM
adj. dropout
adj. intervention completion
REM
adj. dropout
adj. intervention completion
FEM
adj. dropout
adj. intervention completion
REM
adj. dropout
adj. intervention completion

41
40
35
28
31
35
28
31
26
21
23
26
21
23
23
18
15
23
18
15

n.s.
n.s.
n.s.
n.s.
n.s.
n.s.
n.s.
n.s.
b = .2503***
n.s.
b = .2729**
b = .3000**a
n.s.
b = .3080**
n.s.
n.s.
n.s.
n.s.
n.s.
n.s.

26
29
22
17
22
22
17
22
19
14
17
19
14
17
18
13
11
18
13
11

n.s.
bBN = .1709*
n.s.
b = .0083*
n.s.
n.s.
n.s.
n.s.
b = .1115**
n.s.
b = .0857*
b = .1100 p = .0715a
n.s.
b = .0857*
b = .1282***
b = .0834**
b = .1232*
b = .0986 p = .0862a
b = .0836*
b = .1232*

24
26
23
18
22
23
18
22
28
23
25
28
23
25
25
20
17
25
20
17

n.s.
n.s.
n.s.
n.s.
b=
n.s.
n.s.
b=
b=
b=
b=
b=
b=
b=
b=
b=
n.s.
b=
b=
n.s.

21
23
20
15
19
20
15
19
25
20
22
25
20
22
25
20
17
25
20
17

FEM

48

adj. dropout
adj. intervention completion

.0347**

.0310 p = .0594
.1443**
.3404***
.3391***
.1525 p = .0636a
.3272**
.3674**
.2394***
.2566***
.2329* a
.2502 p = .0573

EDE(-Q) Shape
Concern
k
28

22
24

bBED = .4983***
bBN = .2633**
bBED = 1.0226**
n.s.

23
25

bBED = .7495**

27

bBED = .4508**

28

n.s.
n.s.
n.s.
b = .0358**
n.s.
n.s.
b = .0371*
n.s.
b = .1929**
n.s.
b = .1845*
b = .2613 p = .0893
n.s.
n.s.
b = .2993***
b = .2363**
n.s.
b = .2575 p = .0887
b = .2168 p = .0851
n.s.

22
24
21
16
20
21
16
20
25
20
22
25
20
22
25
20
17
25
20
17

n.s.
n.s.
n.s.
n.s.
n.s.
n.s.
n.s.
n.s.
b = .1738**
n.s.
n.s.
b = .1936 p = .0687a
n.s.
n.s.
b = .1504**
n.s.
n.s.
n.s.
n.s.
n.s.

23
25
22
17
21
22
17
21
26
21
23
26
21
23
25
20
17
25
20
17

bBED = .5541***
bBN = .2569**
bBED = .4435*
n.s.
bBED = .5341**
bBN = .2341 p = .0811
n.s.
n.s.
n.s.
n.s.
n.s.
n.s.
n.s.
n.s.
b = .1650**
n.s.
b = .1883**
b = .2025 p = .0516a
n.s.
n.s.
b = .1993**
b = .1597
n.s.
n.s. a
n.s.
n.s.

I. Beintner et al. / Clinical Psychology Review 34 (2014) 158176

Table 4
Results of metaregression analyses for potential intervention effect moderators: patient characteristics.

Outcome measure
Potential moderators

4 week binge eating


frequency
k

Baseline EDE-Q Weight Concern

Baseline EDE-Q Shape Concern

Age

BMI

24
19
21
24
19
21
25
20
22
25
20
22
46
39
40
46
39
40
38
33
35
38
33
35

k
n.s.
b=
n.s.
n.s.
b=
n.s.
b=
b=
n.s.
n.s.
b=
n.s.
b=
b=
b=
b=
b=
b=
b=
b=
b=
b=
b=
b=

.1984*

.1966 p = .0932
.1932*
.2172*

.2111 p = .0653
.0307***
.0201***
.0241***
.0346***
.0204**
.0278**
.0525***
.0311***
.0360***
.0532***
.0274*
.0332*

19
14
17
19
14
17
20
15
18
20
15
18
31
26
29
31
26
29
26
21
24
26
21
24

EDE(-Q) Restraint
k

b=
n.s.
n.s.
n.s.
n.s.
n.s.
b=
b=
n.s.
b=
b=
n.s.
b=
n.s.
b=
b=
n.s.
b=
b=
n.s.
b=
b=
n.s.
b=

.1515**

.1780***
.0790*
.1591*
.0806 p = .0684
.0063***
.0070**
.0083*
.0076*
.0078**
.0107**
.0100 p = .0692a
.0114

p = .0689

25
20
22
25
20
22
26
21
23
26
21
23
29
24
26
29
24
26
28
23
26
28
23
26

EDE(-Q) Eating
Concern
k

b = .2977**
b = .2843 **
n.s.
b = .2830 p = .0753
n.s.
n.s.
b = .1520* a
n.s.
n.s.
n.s.
n.s.
n.s.
n.s.
n.s.
b = .0424***
n.s.
n.s.
b = .0440**
n.s.a
n.s.
b = .0521***
n.s.
n.s.
b = .0533**

25
20
22
25
20
22
25
20
22
25
20
22
26
21
23
26
21
23
25
20
23
25
20
23

EDE(-Q) Weight
Concern
k

b=
b=
n.s.
n.s.
b=
n.s.
b=
b=
n.s.
b=
b=
n.s.
b=
b=
b=
b=
b=
n.s.
b=
b=
b=
b=
n.s.
b=

.3009**
.3371**

.3046*
.3977***
.3643***
.4307*
.3368*
.0460***
.0355***
.0172*
.0453***
.0327**
.0720***
.0410**
.0328**
.0651***
.0319

p = .0669

26
21
23
26
21
23
26
21
23
26
21
23
27
22
24
27
22
24
25
20
23
25
20
23

EDE(-Q) Shape
Concern
k

b=
b=
n.s.
n.s.
b=
n.s.
b=
b=
n.s.
b=
n.s.
n.s.
b=
b=
n.s.
b=
b=
n.s.
b=
n.s.
n.s.
b=
n.s.
n.s.

.2137**
.2641**

.2324*
.2293*
.2183**
.2464 p = .0720

.0242***
.0189**
.0239**
.0194*
.0461***

.0420**

26
21
23
26
21
23
27
22
24
27
22
24
28
23
25
28
23
25
26
21
24
26
21
24

b=
b=
n.s.
n.s.
n.s.
n.s.
b=
b=
n.s.
b=
n.s.
n.s.
b=
b=
b=
b=
b=
b=
b=
b=
b=
b=
n.s.
b=

.2021*
.2172**

.2681***
.2282**
.2475 p = .071a

.0260***
.0200**
.0129*
.0260**
.0202*
.0131 p = 0674
.0498***
.0341*
.0294**
.0462**
.0286*

FEM: xed effects model; REM: random effects model; adj. dropout: metaregression analyses adjusted for dropout rates; adj. intervention completion: metaregression analyses adjusted for intervention completion rates. See Results section for further
details, b: linear regression slope. *pb .05, **pb .01, ***pb .001.
Continuous moderators and covariates were centered around their medians. Categorial moderators with more than two categories were coded as dummy variables.
How to read Tables 3 and 4:
For categorial moderators with two subgroups, b is the difference between the two groups. The reference group is indicated in the subscript. Example: Guidance predicts effects on EDEQ-Restraint in the xed effects model. Effect sizes for EDE-Q
Restraint are increased by .25 in guided self-help compared with unguided self-help (bGSH = .2524**) in the unadjusted xed effects model. Effect sizes are increased by .33 in guided self-help compared with unguided self-help (bGSH =
.3295) if the xed effects model is adjusted for dropout rates. Effect sizes are increased by .47 in guided self-help compared with unguided self-help (bGSH = .4714) if the xed effects model is adjusted for intervention completion rates and denitions.
Guidance does not predict effects on EDEQ-Restraint in the xed effects model.
For categorial moderators with three subgroups, b is the difference between one group and the other two groups. The reference group is indicated in the subscript. Example: Intervention type predicts effects on 4 week binge eating frequency. Effect
sizes for the reduction of binge eating frequency are reduced by .27 in CD-ROM interventions compared with bibliotherapy and Internet-based interventions (bCD-ROM = .2692*) in the unadjusted xed effects model.
For continuous moderators, b indicates the change in effect sizes if the value of the moderator is increased by one unit. Example: Number of sessions predicts abstinence rate. Each additional session to the overall median number of session increases the
abstinence rate by 1.08% (b = .0108***) in the unadjusted xed effects model.
a
Substantial changes of results in sensitivity analyses.

I. Beintner et al. / Clinical Psychology Review 34 (2014) 158176

FEM
adj. dropout
adj. intervention completion
REM
adj. dropout
adj. intervention completion
FEM
adj. dropout
adj. intervention completion
REM
adj. dropout
adj. intervention completion
FEM
adj. dropout
adj. intervention completion
REM
adj. dropout
adj. intervention completion
FEM
adj. dropout
adj. intervention completion
REM
adj. dropout
adj. intervention completion

Abstinence from binge


eating

169

170

I. Beintner et al. / Clinical Psychology Review 34 (2014) 158176

participants signicantly predict effect sizes for the EDE(-Q) Restraint


scale in the xed effects model (see Tables 4 and C.2).
The frequency of binge eating at baseline predicts effect sizes for the
EDE(-Q) Eating Concerns scale in the random effects model. Higher frequencies of binge eating at baseline are associated with smaller effect
sizes for the EDE(-Q) Eating Concern scale in the random effects model
adjusted for dropout rates. In addition, the frequency of binge eating
at baseline predicts abstinence from binge eating and effect sizes for
the EDE(-Q) Restraint scale in the xed effects model (see Table 4). All results are consistent.
EDE(-Q) Restraint scores at baseline predict effect sizes for the frequency of binge eating episodes, abstinence from binge eating, and effect sizes for the EDE(-Q) Restraint scale in the random effects model.
Higher scores on the EDE(-Q) Restraint scale at baseline are associated
with a smaller effect size for the frequency of binge eating episodes
and with lower abstinence rates in the unadjusted random effects
model and in the random effects model adjusted for intervention completion rates and intervention completion denitions. Higher scores
on the EDE(-Q) Restraint scale at baseline are associated with a larger
effect size for the EDE(-Q) Restraint scale in all models. In addition,
EDE(-Q) Restraint scores at baseline predict effect sizes for the EDE(-Q)
Eating, Weight and Shape Concern scales in the random effects model
(see Table 4). All results are consistent.
EDE(-Q) Eating Concern scores at baseline predict abstinence from
binge eating, and effect sizes for the EDE(-Q) Restraint scale in the
random effects model. Higher scores on the EDE( Q) Eating Concern
scale at baseline are associated with higher abstinence rates in both
the adjusted random effects models. Higher scores on the EDE(-Q) Eating
Concern scale at baseline are associated with a larger effect size for the
EDE(-Q) Restraint scale in the unadjusted random effects model. In addition, EDE(-Q) Restraint scores at baseline predict effect sizes for the
EDE(-Q) Eating, Weight and Shape Concern scales in the xed effects
model (see Table 4). All results are consistent.
EDE(-Q) Weight Concern scores at baseline predict effect sizes for the
EDE(-Q) Eating and Weight Concern scales in the random effects model.
Higher scores on the EDE(-Q) Weight Concern scale at baseline are associated with larger effect sizes for the EDE(-Q) Eating and Weight Concern scales in the random xed effects model adjusted for dropout
rates. In addition, EDE(-Q) Weight Concern scores at baseline predict
effect sizes for the frequency of binge eating episodes, abstinence from
binge eating and effect sizes for the EDE(-Q) Restraint and Shape
Concern scales in the xed effects model (see Table 4). All results are
consistent.
EDE(-Q) Shape Concern scores at baseline predict abstinence from
binge eating and effect sizes for the EDE(-Q) Eating Concern scale in
the random effects model. Higher scores on the EDE(-Q) Shape Concern
scale at baseline are associated with larger effect sizes for the frequency
of binge eating episodes in the unadjusted random effects model. Higher
scores on the EDE(-Q) Shape Concern scale at baseline are associated
with larger effect sizes for the EDE(-Q) Eating Concern scale in the unadjusted random effects model and in the random effects model adjusted for
dropout rates. In addition, EDE(-Q) Shape Concern scores at baseline
predict effect sizes for the frequency of binge eating episodes, effect
sizes for the EDE(-Q) Restraint, Weight and Shape Concern scales in
the xed effects model (see Table 4). All results are consistent.
Participants' age predicts effect sizes for the frequency of binge eating
episodes, abstinence from binge eating and effect sizes for the EDE(-Q)
Restraint, Eating, Weight and Shape Concern scales in the random effects
model. A higher age is associated with larger effect sizes for the frequency of binge eating episodes in all models. A higher age is associated with
higher abstinence rates in the unadjusted random effects model and the
random effects model adjusted for intervention completion rates and
intervention completion denitions. A higher age is associated with
smaller effects for the EDE(-Q) Restraint scale in the random effects
model adjusted for intervention completion rates and intervention completion denitions. A higher age is associated with larger effects for the

EDE(-Q) Eating Concern scale in the unadjusted random effects model


and the random effects model adjusted for dropout rates. A higher age
is associated with larger effects for the EDE(-Q) Weight Concern scale
in the unadjusted random effects model and the random effects model
adjusted for dropout rates. A higher age is associated with larger effect
sizes for the EDE(-Q) Shape Concern scale in the unadjusted random
effects model and the random effects model adjusted for dropout rates.
All results are consistent.
Participants' BMI predicts effect sizes for the frequency of binge eating
episodes, and the EDE(-Q) Restraint, Eating, Weight and Shape Concern
scales in the random effects model. A higher BMI is associated with larger
effect sizes for the frequency of binge eating episodes in all models. A
higher BMI is associated with smaller effects for the EDE(-Q) Restraint
scale in the random effects model adjusted for intervention completion
rates and intervention completion denitions. A higher BMI is associated
with larger effects for the EDE(-Q) Eating Concern scale in the unadjusted
random effects model. A higher BMI is associated with larger effects for the
EDE(-Q) Weight Concern scale in the unadjusted random effects model. A
higher BMI is associated with larger effects for the EDE(-Q) Shape Concern scale in the unadjusted random effects model, and the random effects
model adjusted for intervention completion rates and intervention completion denitions. In addition, participants' BMI predicts effect sizes for
the frequency of binge eating episodes, abstinence from binge eating
and effect sizes for the EDE(-Q) Restraint, Eating, Weight and Shape
Concern scales in the random effects model (see Table 4). All results are
consistent.
3.6. Sensitivity analyses
All unadjusted analyses were repeated with exclusion of interventions which had allowed additional pharmacotherapy or a placebo
medication to the self-help intervention. Results are summarized in
Appendix D.
4. Discussion
The objective of this meta-analysis analysis was to shed light on the
complex associations between study, intervention and patient characteristics, patient participation measures, and intervention outcomes in
manualized self-help-trials for bulimia nervosa and binge eating disorder. We examined the different measures of patient participation reported in the individual studies and integrated these measures across
the different trials. Subsequently, we identied moderators of participation and intervention outcomes. Lastly, we examined if and how associations between moderators and intervention outcomes are affected by
participation measures. Results from metaregression analyses are
prone to aggregation bias, especially when investigating the role of patient characteristics. The association between average patient characteristics and outcomes across trials may be entirely different from the
association between patients' individual data and the same outcome
within individual trials (Thompson & Higgins, 2002). We therefore
compare our ndings to ndings regarding moderators from the individual studies and discuss potential discrepancies.
4.1. Measures of participation
Authors reported study dropout rates (i.e., rates of participants not
completing post-intervention assessments) for 51 of the intervention
conditions as a rather broad participation measure. The range of study
dropout rates was very large (1% to 88% with a median of 25%). The
range of these rates is comparable to that reported for self-help interventions for other mental disorders (e.g., 2-83% in Internet-based treatment programs for psychological disorders in general (Melville et al.,
2010) and 150% in randomized controlled trials examining Internetbased interventions for anxiety and depression (Christensen et al.,
2009)). Similarly, mean drop-out rates in outpatient psychotherapy

I. Beintner et al. / Clinical Psychology Review 34 (2014) 158176

trials for eating disorders range from 29% to 73% (Fassino, Piero, Tomba,
& Abbate-Daga, 2009).
Between 1% and 88% of participants in 51 intervention conditions
completed the intervention to which they had been assigned. However,
intervention completion was dened inconsistently by study authors.
Most frequently, authors used objective measures to dene intervention
completion such as the number of guidance sessions a participant had received or the number of times a participant had logged on to an Internet
platform (k = 18). In a substantial number of conditions, intervention
completion was merely dened as the provision of post-intervention
data (k = 9). Also, in some studies, intervention completion was dened
based on participants' report rather than on objective measures (k = 12).
Lastly, in a considerable number of studies authors did not specify their
denition of intervention completion at all (k = 11).
Some of the authors provided very detailed information on intervention participation, thus enabling us to determine the number of patients
who received a certain dosage of the intervention. In 11 conditions, information was given on how many participants completed threequarters of the intervention; these rates range from 20% to 81%. In 13
conditions, information was given on how many participants completed
less than half of the intervention; these rates range from 17% to 58%.
4.2. Moderators of participation
A number of study, intervention, and patient characteristics were
found to be signicantly associated with participation measures. However, only some of the associations turned out to be robust based on
the results of both xed and random effects models and only these
will be discussed here in more detail.
Study dropout, which is the weakest, albeit most commonly reported
indicator of participation, is robustly predicted by the type of intervention, participants' diagnoses, age and body mass index (BMI), and baseline EDE( Q)-Restraint. Study dropout rates are lowest in Internetbased interventions and highest in CD-ROM interventions. More
patients in studies recruiting patients with binge eating disorder
(BED) completed post-intervention assessments than in studies
recruiting patients with bulimia nervosa (BN). Participants in studies
recruiting patients with BED exhibited less EDE( Q) Restraint, were
older, and had higher BMIs than participants in studies recruiting patients with BN and a higher age, higher BMI and lower baseline
EDE(-Q) Restraint are also associated with lower study dropout rates.
When comparing our results with the ndings from individual studies, study dropout in patients with bulimia nervosa exceeded study
dropout in patients with binge eating disorder (Graham & Walton,
2011) in one individual study. Also in line with our ndings, in two
studies patients with higher dietary restraint (Ramklint, Jeansson,
Holmgren, & Ghaderi, 2012; Wilson et al., 2000) were more prone to
dropout. None of the individual studies showed associations contrary
to our own ndings. In addition to the moderators detected in the
metaanalysis, eating concern (Pritchard, Bergin, & Wade, 2004; Wilson
et al., 2000), weight concern (Jones et al., 2012; Wilson et al., 2000),
and shape concern (Carrard, Crepin, Rouget, Lam, Golay, et al., 2011;
Pritchard et al., 2004; Wilson et al., 2000) were associated with study
dropout. A higher binge eating frequency at baseline was associated
with a higher dropout rate in a subsample of the SALUT study
(Carrard et al., 2006), but not in the full sample (Carrard, FernandezAranda, et al., 2011). In one study, associations between patient characteristics and dropout varied greatly between sites (Mitchell et al., 2011).
In a number of other individual studies, authors did not nd any significant differences between study dropouts and study completers
(Banasiak, Paxton, & Hay, 2005; Cassin, 2008; Furber et al., 2004;
Ghaderi, 2006; Loeb, Wilson, Gilbert, & Labouvie, 2000; Schmidt et al.,
2008; Treasure, Schmidt, Troop, & Todd, 1996).
Treatment completion rates could not be robustly predicted by any of
the study, treatment and patient characteristics, even after adjusting for
intervention completion denitions.

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In the subset of studies with more detailed information on the dosage of intervention participants had received, the rate of participants
who completed more than 75% of the intervention was robustly predicted
by study design and intervention type. More patients in RCTs and in bibliotherapy completed at least three quarters of the intervention. The rate
of participants who completed less than 50% of the intervention was robustly predicted by guidance and participants' diagnoses, age, and
BMI. More participants in unguided self-help and more participants in
studies recruiting BN patients, younger patients, and patients with a
lower BMI completed less than half of the intervention.
In some of the individual studies, moderators of participation were
reported, but ndings are heterogeneous and none of the ndings
from individual studies are consistent with the ndings from our
metaanalysis: A higher frequency of binge eating and vomiting was associated with failure to engage in the intervention in one study (BaraCarril et al., 2004), while in another, there were no differences in symptom severity between patients who engaged in the intervention and
those who did not (Murray et al., 2003). In one study, participants
who completed more than half of the sessions had higher baseline
EDE(-Q) Eating Concern scores at baseline (Pretorius et al., 2009)
while higher EDE(-Q) Weight Concern scores were associated with
poorer overall compliance in another study (Troop et al., 1996). Patients
who exhibited greater dietary restraint at baseline reported having read
more chapters of the self-help book provided in one study (Thiels et al.,
2001), while in another no differences between intervention completers and noncompleters were found (Steele & Wade, 2008). These inconsistencies are likely to at least in part result from inconsistent
denitions and measures of participation.
4.3. Moderators of intervention outcomes
As anticipated, associations between study, intervention, and patient
characteristics and intervention outcomes varied depending on whether
study dropout or intervention completion rates were taken into account
or not. Not all associations were robust and remained statistically signicant after adjusting. For an overview of associations that proved to be
statistical artifacts after adjusting and associations that could only be detected after adjusting, please view Tables 3 and 4. Here, we will discuss robust ndings (i.e., those conrmed in both the xed and random effects
model adjusted for study dropout rates, or in both the xed and random
effects model adjusted for intervention completion rates and intervention
completion denitions).
Intervention type predicted the reduction in binge eating frequency
and in EDE(-Q) Restraint scores, with Internet-based interventions
yielding better outcomes. Guidance predicted the reduction in binge
eating frequency, abstinence from binge eating and the reduction in
EDE(-Q) Eating, Weight, and Shape Concerns, with guided self-help
yielding better outcomes. A higher number of sessions in guided selfhelp predicted abstinence from binge eating, the reduction in EDE(-Q)
Restraint, Weight and Shape Concerns, with more sessions yielding better outcomes.
Participants' diagnoses predicted abstinence from binge eating, with
samples of BED patients yielding better outcomes. Participants' baseline
EDE(-Q) Eating and Shape Concern scores predicted abstinence from
binge eating and the reduction in EDE(-Q) Restraint with patients
with higher baseline scores yielding better outcomes. Participants' baseline EDE(-Q) Eating, Weight and Shape Concern scores predicted the reduction in binge eating frequency and in EDE(-Q) Eating Concern with
patients with higher baseline scores yielding better outcomes. Participants' baseline binge eating frequency predicted the reduction in
EDE(-Q) Restraint and Eating Concern, with patients reporting more
binge eating episodes at baseline yielding better outcomes of EDE(-Q)
Restraint and poorer outcomes of EDE(-Q) Eating Concern. Participants'
baseline EDE(-Q) Restraint level predicted the reduction in binge eating
frequency and abstinence from binge eating with patients with higher
baseline scores achieving poorer outcomes. However, associations

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between participants' baseline levels of EDE(-Q) Restraint, EDE(-Q)


Eating, and Weight Concern scores and reductions in the respective
scales must be interpreted with caution, since oor effects are likely to
inuence these effects. Participants' age predicted the reduction in
binge eating frequency, abstinence from binge eating, and the reduction
in EDE(-Q) Restraint, Eating, Weight, and Shape Concerns; samples with
older patients showing poorer outcomes in EDE(-Q) Restraint and better
outcomes in the other outcome measures. Participants' BMI predicted the
reduction in binge eating frequency, abstinence from binge eating, and
the reduction in EDE(-Q) Restraint, Eating, and Shape Concerns; samples
of patients with higher BMIs yielding poorer outcomes in EDE(-Q) Restraint and better outcomes in the other outcome measures.
Overall, participants' age predicted the highest number of outcomes (all 6 analyzed outcomes), followed by guidance, participants' BMI, the number of sessions in guided self-help, and participants'
baseline EDE(-Q) Restraint, scores (3 outcomes). Participants' age could
either be a proxy for illness duration and illness related distress and
thus motivation to change is increasing along with illness duration or
it could be related to participants' diagnoses, as the mean age of onset
for BN is lower than for BED (Kessler et al., 2013). Both abstinence from
binge eating and binge eating frequency as the core outcomes of BN and
BED were robustly predicted by guidance, participants' baseline
EDE(-Q) Restraint and Shape Concerns, and participants' BMI and age.
Within individual studies, reports on moderators of intervention
outcomes were scarce, and ndings were heterogeneous. In our
metaanalysis, abstinence rates were higher in samples of BED patients
when not adjusting for dropout rates. However, when adjusting for
dropout rates, abstinence rates in samples of BED patients were lower,
so across studies, differences in abstinence rates must partly be attributed to differences in dropout. In one individual study, improvements regarding binge eating episodes were greater for patients with BED than
for those with BN (Ljotsson et al., 2007), while in another study, there
were no differences in improvements made by patients with BN and
BED (Graham & Walton, 2011). Baseline binge eating frequency predicted improvements in EDE(-Q) Restraint and Eating Concern, but not in
binge eating in our metaanalysis. In two of the individual studies, a
higher binge eating frequency at baseline was associated with a poorer
outcome (Loeb et al., 2000; Thiels, Schmidt, Troop, Treasure, & Garthe,
2000), while symptom severity did not predict intervention response
in two other studies (Cooper, Coker, & Fleming, 1996; Masheb & Grilo,
2008). In our metaanalysis, higher EDE( Q) Shape Concern scores at
baseline were associated with greater improvements regarding binge
eating. In one of the individual studies, the opposite was the case: a
greater overevaluation of weight and shape at baseline was associated
with a higher binge eating frequency at post-intervention (Steele,
Bergin, & Wade, 2011). In our metaanalysis, abstinence rates were
higher in samples of older patients, while in one of the individual studies, binge remission was not associated with age (Masheb & Grilo,
2008).
4.4. Implications for the design of future interventions
In the absence of clear guidelines to determine the clinical relevance
of a statistically signicant association between a moderator and an outcome we decided to consider and discuss each association separately.
This approach was chosen to illustrate the cost and benets of changes
in the design and other characteristics of the interventions for both the
provider of the intervention (usually the clinician) and the patient.
4.4.1. How should self-help interventions be designed to maximize
participation and intervention outcome?
Study dropout rates in bibliotherapy and CD-ROM based interventions are up to twice as high as study dropout rates in Internet-based
interventions (mean difference: 14%). Partly this may be due to the
fact that in all but one of the CD-ROM intervention conditions, participants had to come to a clinic to access the intervention. In unguided

self-help, about half of the patients completed less than 50% of the treatment. In guided self-help, this was true for only just a third of patients
patients are less likely to drop out of the intervention in the rst half if
they receive guided self-help. In bibliotherapy, almost two out of three
patients completed more than 75% of the intervention, while in CDROM and Internet-based interventions just over one out of three
patients did so. Participation is dened differently, though: In Internetbased interventions participation is usually measured electronically,
with every page opened recorded in a participant log. Completing more
than 75% of the intervention was therefore dened as having worked
through 75% of the Internet modules. On the other hand, all of the bibliotherapy interventions with sufcient information to determine how
many patients had completed more than 75% of the intervention were
guided self-help interventions, and completing more than 75% of the intervention here was dened as having attended 75% of the guidance sessions. Not surprisingly, patients may feel more obliged to keep face to face
appointments with a person than to log on to an Internet-platform, and
although all Internet-based interventions were guided too by email, personal contact may help patients keep up with the self-help program.
However, if similar intervention completion rates could be achieved in
Internet-based interventions, they might be superior to bibliotherapy
and CD-ROM interventions regarding the reduction of binge eating frequency and dietary restraint supported by the larger effect sizes (.49
and .72) of these interventions.
Guidance had the strongest impact on effect sizes of eating disorder
related attitudes, with guided self-help yielding effect sizes by .42.67
larger than unguided self-help when assuming similar dropout or intervention completion rates. Impact on the reduction of binge eating and
abstinence from binge eating was smaller, but abstinence rates in guided self-help were still more than twice as high as in unguided self-help
and effect sizes for the reduction of binge eating was by .25 larger in
guided self-help. The number of sessions in guided self-help had the
strongest impact on the reduction of dietary restraint, with just one additional session to the median number of 8 sessions increasing the effect
sizes by .20. Effects on abstinence from binge eating and weight and
shape concerns were smaller. Five additional sessions would raise abstinence rates by 10%; and two to four additional sessions would raise the
effect sizes for weight and shape concerns by .20. Previous research has
shown that especially patients with chronic bulimia nervosa are less
motivated and condent to change dietary restraint in comparison to
binge eating (Perkins et al., 2007). Guidance may play an important
role in tackling patients' fears of giving up restrained eating.
Our ndings show that in self-help for bulimia nervosa and binge
eating disorder, guidance can improve both intervention participation
and outcomes. The same was true for self-help studies addressing mental disorders other than eating disorders (e.g., Christensen, Grifths,
Korten, Brittliffe, & Groves, 2004; Clarke et al., 2005; Kenwright,
Marks, Graham, Franses, & Mataix-Cols, 2005; Simon et al., 2011). Likewise, interventions, such as counseling or social support, have also been
shown to facilitate adherence to medical regimens and other selfmanagement behaviors (Roter et al., 1998). Across all guided self-help
conditions, the guides' qualication was associated with intervention
completion and key outcomes, namely the reduction of binge eating
and weight and shape concerns, with guidance by eating disorder
specialists, CBT therapists or mental health specialists, yielding better
results than nurse or GP. Findings also indicate that face-to-face guidance may lead to better intervention participation than email guidance.
Internet-based interventions may have some advantages over bibliotherapy regarding outcomes, but ways to improve participation in
such interventions are needed. In the SALUT study, authors reported signicant differences in study dropout rates between coaches, with two
coaches retaining a markedly higher number of patients in the intervention. Interviews with the coaches showed that these coaches provided
more support and had a more therapeutic approach or monitored participants in a more diligent way (Carrard, Fernandez-Aranda, et al.,
2011). The advantages of face-to-face guidance in bibliotherapy could

I. Beintner et al. / Clinical Psychology Review 34 (2014) 158176

be combined with the possible advantages of Internet-based interventions such as interactive elements or immediate feedback by augmenting email guidance with (view)phone guidance, or by providing
guidance by specialists.
4.4.2. Who benets most from self-help interventions?
Study dropout rates are up to twice as high in studies with either BN
patients only or studies with mixed samples of both BN and BED patients compared with studies with BED patients only. Each additional
point on the mean EDE(-Q) Restraint Scale score (with scores ranging
from 0 to 6) in a study sample adds 16% to the dropout rate. Each additional 10 years of mean age in a study sample reduces the dropout rate
by 6%. Similarly, each additional 10 BMI points of mean BMI in a study
sample reduces the dropout rate by 16%. In summary, study dropout
rates are substantially lower in studies with BED patients who also
tend to exhibit less dietary restraint, are older, and have higher BMIs.
While almost every second patient in samples with BN patients dropped
out of the intervention in the rst half, only about one in four patients
did so in samples with BED patients and mixed samples with both BN
and BED patients.
Participants' diagnoses were clearly associated with only one outcome: participants in studies recruiting only BN patients were less likely
to be abstinent from binge eating than participants in studies recruiting
only BED patients or both BN and BED patients, with 17% lower abstinence rates when assuming similar intervention completion rates.
Age, BMI, and EDE-(Q) Restraint (which are very likely to be confounded with the diagnoses) showed associations with more outcomes. To
illustrate these ndings, we compare a hypothetical sample of patients
on average 40 years of age with a hypothetical sample of patients on average 30 years of age, assuming similar study dropout and intervention
completion rates. Based on our data, the older sample would for example yield an effect size smaller by .44 in the reduction of dietary restraint, an effect size higher by .20.28 for the reduction in binge
eating and an effect size higher by .33 for the reduction in eating concerns compared with the younger sample. We found a similar pattern
for participants' BMI. Again, based on a hypothetical sample of patients
in the normal weight range with an average BMI of 22.5 kg/m2 compared with a hypothetical sample of overweight and obese patients
with an average BMI of 32.5 kg/m2 and assuming similar study dropout
and intervention completion rates, the sample of overweight and obese
patients would have an effect size smaller by .53 for the reduction in dietary restraint, larger effect sizes higher by .27.36 for the reduction in
binge eating and effect sizes larger by .32 and .29 for the reduction of
eating and shape concerns. Also, abstinence rates would differ by 11%
in favor of the sample of overweight and obese patients.
Higher degrees of baseline EDE(-Q) Restraint will less likely result in
lower rates of binge eating at post-intervention: Again, translated to a
hypothetical sample whose average baseline EDE(-Q) Restraint score
is 3.0, the effect size for the reduction in binge eating would be larger
by .30 and the abstinence rate would be 9% higher compared with a
hypothetical sample whose average baseline EDE(-Q) Restraint score
is 4.0, assuming similar intervention completion rates.
Baseline binge eating frequency, which is a proxy for symptom severity was positively associated with the reduction in EDE(-Q) Restraint
and negatively associated with the reduction of EDE(-Q) Eating Concern. A higher symptom severity at baseline was linked to both higher
baseline EDE(-Q) Restraint and Eating Concern, thus in theory allowing
for a larger improvement in both measures. When looking across individual studies, effect sizes for the reduction of EDE(-Q) Eating Concern
tend to be larger than for EDE(-Q) Restraint. However, our ndings suggest especially that in samples of patients with more severe baseline
symptoms, the reduction of dietary restraint might be easier to achieve
than the reduction of concerns about eating.
Eating concern at baseline is positively associated with abstinence
rates of binge eating and the reduction in EDE(-Q) Restraint. The
EDE(-Q) Eating Concern scale covers several items regarding shame or

173

guilt about eating, hence this scale might indirectly measure the amount
of suffering from the eating disorder; individuals who experience higher
levels of suffering might have a higher motivation to change and hence
benet more from an intervention.
Weight, and shape concerns at baseline are positively associated
with the reduction of binge eating and eating concern. Again, higher
weight and shape concerns may be associated with higher levels of suffering and a higher motivation to change.
4.5. Clinical recommendations
Our ndings suggest that BED patients (who are older, have a higher
BMI, and exhibit less dietary restraint at baseline) are more likely to persist with the self-help intervention, and even beyond the effect of different intervention completion rates, might benet substantially more
from self-help interventions than BN patients. In the treatment of eating
disorders, reestablishing a pattern of regular eating is usually the rst
step. From our own clinical experience, BN and BED patients differ in
their motivation, fears and ambivalence regarding those changes in eating behavior: BED patients, even after learning that weight loss will not
be the focus of treatment, often hope to lose weight once their eating
behavior has changed. Their eating behavior outside binge eating episodes is often unstructured, while they do not feel more guilty about
eating than healthy controls (Wiley, Schwartz, Spurrell, & Fairburn,
2000). To normalize their eating behavior, they need to structure their
meals, but they do not need to increase the amount of calories consumed between binge eating episodes. BN patients have an intense
fear of gaining large amounts of weight (Treasure & Schmidt, 2008)
once they exchange their pattern of alternately dieting, binge eating,
and compensating for regular meals and snacks. Their eating behavior
outside binge eating episodes is often restricted and they feel guilty
about eating (Wiley et al., 2000). To normalize their eating behavior,
they need to increase the amount of calories consumed between binge
eating episodes, and their initial motivation to do this is often low
(Perkins et al., 2007). The initial changes during treatment might thus
be a lot harder for BN than BED patients, and their fears may not have
been addressed adequately by some of the previous self-help interventions, causing them to drop out of treatment more frequently, or
resulting in poorer outcomes.
In line with these considerations, we also found that in studies with
BN patients guidance was associated with higher intervention completion rates, higher abstinence from binge eating, and greater reduction
of dietary restraint (detailed data available upon request). It therefore
seems that BN patients, compared with BED patients, need more encouragement and support during self-help interventions, which can be
better provided by a non-virtual guide. Also, our data suggest that the
guides' qualication is not trivial, and guidance provided by mental
health specialists is associated with better treatment completion rates
and larger effects on key outcomes than non-specialist guidance.
It can be argued that specialist guidance is more costly and makes
treatment dissemination more difcult than non-specialist guidance.
From a pragmatic point of view, smaller effect sizes sometimes may
need to be accepted in order to reach more people. However, one has
to consider that patients with mental disorders may attribute treatment
failure to internal factors rather than the treatment and thus, their motivation and condence to change their behavior are likely to be compromised by poorly delivered initial treatment. Therefore, guides
should be chosen carefully, and should be trained sufciently in how
to guide patients, and intervention delity should be regularly monitored and maximized. Studies on adherence in medicine taking behavior have consistently shown that in general interventions to
promote adherence are efcacious (Horne et al., 2005). Considering variables associated with guidance might however be only one means of
improving adherence. A variety of other variables not reported in the
studies included in our review, such as patients' health beliefs, illnessrelated attitudes, or other variables related to the patients' specic

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needs and preferences as well as other characteristics of the intervention might also be important to increase adherence behavior.
4.6. Limitations of our metaanalysis
For reasons of clarity and readability, we limited the treatment outcomes included in our meta-analyses. As the reduction of compensatory
behaviors is relevant as an outcome only in patients with BN, we chose
to exclude this outcome from our analyses. In studies on treatment outcome and long-term course of bulimia nervosa, binge eating and compensatory behaviors are usually highly correlated (e.g., Edler, Haedt, &
Keel, 2007). However, we are aware that in patients with BN, the reduction of compensatory behavior might be a more conservative indicator
for overall symptom reduction and long-term outcome than the reduction of binge eating (Agras et al., 2000; Fahy & Russell, 1993).
Our ndings are limited by the inclusion of case series and the calculation of prepost-effect sizes for the intervention groups only rather
than controlled effect sizes. However, since the number of randomized
controlled trials on manualized self-help interventions with an untreated control group is limited to 13 studies so far, moderator effects would
have been difcult to detect and very likely hard to interpret.
A major limitation of our meta-analysis is the high variability of definitions of intervention completion across the included studies. Researchers vary in their use of terms to describe the premature
termination of an intervention or study; terms like dropout, treatment dropout, attrition, non-usage, non-compliance are sometimes used interchangeably, denitions are arbitrary or unclear and
the evaluation of dropout rates is complicated by the lack of a consistent
operationalization (Melville et al., 2010). Not surprisingly, in our metaanalysis, the number of denitions of intervention completion was almost as high as the number of included studies. At this point it must
therefore remain unclear if the absence of conrmed moderators of intervention completion is related solely to the lack of a gold standard of
reporting intervention participation in self-help or if patient characteristics other than those primarily included in intervention trials may
moderate participation in self-help interventions.
Other limitations may result from the employment of metaregression
to identify potential moderators of participation and outcomes. Causal interpretations are impossible with this approach. Associations with one
trial characteristic may reect an underlying association with another,
possibly unknown, correlated characteristic. Also, as stated above, patient
characteristics need to be averaged for each trial, and associations observed across trials may be different from associations observed within
each trial (aggregation bias). Also, information on potential moderators
was only available for a subset of studies. Analyses are therefore based
on these subsets rather than on the full sample, which could also bias results (Thompson & Higgins, 2002). Findings of our moderator analyses
can however, be used to generate hypotheses to be investigated in future
trials.
To enhance comparability between effect sizes, we used or calculated ITT effect sizes for all studies. To estimate ITT effect sizes from completer data, for pragmatic reasons we assumed a zero effect for study
dropouts. This method resembles the simple and highly criticized imputation method of carrying the baseline observation forward utilized in
clinical trials, which arbitrarily assumes that participants who drop
out from a study do not change between pre- and post-intervention assessments. While for clinical trials, more adequate methods of data imputation are available (Little et al., 2012), this is not the case for
metaanalyses. In our review, effect sizes in trials with large dropout
rates may thereby be systematically underestimated. However, when
adjusting metaregression analyses of potential moderators for dropout
rates, this bias is likely to be minimized. Lastly, we cannot be sure how
many of the trial participants received a self-help intervention solely
or some additional intervention (e.g., counseling, medication, other
treatment). The majority of trials testing self-help interventions did
not explicitly exclude patients currently on medication, nor did they

report how many participants took antidepressants at a dosage that


might have affected their eating disorder. We therefore decided not to
exclude studies augmenting self-help with medication (or vice versa).
Nevertheless, it can be assumed that the effect of medication on core
eating disorder symptoms and related behaviors and attitudes is different from the effect of a self-help intervention: Fluoxetine, for example,
has been shown to reduce binge eating and purging, but little is
known about its effect on specic eating disorder related attitudes and
behaviors such as dietary restraint and weight concern (Steinglass
& Walsh, 2004). Also, recovery rates are low (Flament, Bissada, &
Spettigue, 2012). Orlistat on the other hand works by preventing the absorption of fat in the body (Guerciolini, 1997) (with a number of highly
unpleasant gastrointestinal side effects) and is unlikely to affect appetite, the urge to binge, or eating disorder related attitudes and behaviors.
Orlistat would potentially prevent patients from binge eating high fat
foods, but not prevent them from binge eating at all in the long run. In
the sensitivity analyses, we could not detect any systematic differences
between interventions augmenting self-help with medication and those
providing self-help only.
5. Conclusion
Self-help interventions can contribute to bridging the treatment gap
for bulimia nervosa (BN) and binge eating disorder (BED), especially if
the features of their delivery and indications are considered carefully.
While patients with BED might benet from both guided and unguided
self-help, guidance seems especially important for patients with BN,
both to help them keep up with the self-help intervention and to
achieve symptom improvements.
Also, our ndings suggest that interventions guided by mental
health specialists are more effective than interventions guided by nonspecialists. Partly this could result from specialists' detailed knowledge
on eating disorders and their treatment, but specialists might also pursue a more patient centered approach to guidance, which has been
thought to impact both adherence and outcomes of interventions
(Horne et al., 2005).
However, further qualitative and quantitative research is needed to
determine what optimal guidance is, what a good guide should and
should not do, if poor guidance can do any harm, or what kind or dosage
of guidance would meet the needs of the majority of patients. Such research could follow investigations on the patient provider interaction
and on health care communication, examining the context, process,
and content of guidance. In addition, examining the patients' beliefs
and their perspectives of illness and treatment and addressing these in
interventions might help explain individual variations in adherence
and thus increase adherence behavior (Horne et al., 2005).
According to the WHO, adherence is an important indicator of
health system effectiveness (Sabat, 2001, p 8), and thus, for the effectiveness of self-help interventions. Because we could show that associations between moderators and treatment effects based on intent-totreat samples are noticeably affected by study drop-out or treatment
completion rates we suggest that information about dropout and treatment completion be taken into account in future metaregressionanalyses.
A major challenge in our meta-analysis was the lack of a standard for
reporting adherence or participation in the studies. As a consequence,
we were unable to determine to what degree participation depends
on either intervention or patient characteristics, and what degree of
participation is needed to achieve a certain outcome. To further improve
self-help interventions and to be able to tailor them to the specic needs
of different subgroups of participants, a number of usage and dropout
attrition metrics can (and should) be provided in addition to efcacy
measures (Eysenbach, 2005) when reporting the results of self-help
studies, and there should be a more consistent approach to operationalize
those measures. Firstly, authors should clearly distinguish between study
dropout (i.e., the failure to complete assessments) and intervention

I. Beintner et al. / Clinical Psychology Review 34 (2014) 158176

dropout (i.e., the failure to complete the intervention). Secondly, participants who terminated the intervention prematurely should not per se
be excluded from post-intervention assessments. Thirdly, authors should
provide detailed information on how and to what degree or dosage
participants used the program. Especially with online interventions,
these data would be relatively easy to obtain and report and could be
illustrated as attrition curves (Eysenbach, 2005). Reporting measures of
participation more consistently and explicitly will further contribute to
our understanding of what kind of interventions will be utilized most likely by patients, who specically will benet most from them, and how they
work best.

Appendix A. Supplementary data


Supplementary data to this article can be found online at http://dx.
doi.org/10.1016/j.cpr.2014.01.003.

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